Provider First Line Business Practice Location Address: 
521 N BRIGHTLEAF BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SMITHFIELD
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27577-4407
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
919-989-5500
    Provider Business Practice Location Address Fax Number: 
919-989-5532
    Provider Enumeration Date: 
08/30/2006